Health inspection·September 20, 2023

F 0760 Ensure that residents are free from significant medication errors. Level of Harm - Minimal harm or potential for actual harm **NOTE- TERMS IN BRACKETS HAVE BEEN EDITED TO PROTECT CONFIDENTIALITY** Based on interview and record review, the facility failed to administer Heparin Sodium Injection Solution 5000 Unit/ml (a medication used to prevent and treat blood clots and other clotting-related conditions) for one (Resident 1) of four sampled residents. Residents Affected - Few This failure resulted in Resident 1 not receiving medications as per physician's orders and placing Resident 1 at high risk for developing a blood clot. Findings: During a review of Resident 1's admission record, printed on 9/20/23, the admission record indicated Resident 1 was originally admitted to the facility on [DATE]. During a review of Resident 1's Physician orders dated 8/23/23, the Physician orders indicated to administer Heparin Sodium (Porcine) Injection Solution 5000 Unit/ml subcutaneously (injected into the tissue between the skin and muscle) every 12 hours (9:00 a.m. and 9:00 p.m.) for DVT (Deep vein thrombosis -a condition in which the blood clots form in veins located deep inside the body, usually in the thigh or lower legs) Prophylaxis. During a concurrent interview and record review on 9/20/23, at 2:15 p.m. with Licensed Vocational Nurse (LVN) 1, Resident 1's Medication administration record (MAR), dated 8/2023 and Progress notes , dated 8/23/23 and 8/24/23 were reviewed. The MAR indicated, on 8/23/23, for the 9 a.m. administration time and for 8/24/23 at 9 .00 p.m., administration time, the MAR was coded 9 . LVN 1 stated that code 9 indicated the medication was not administered. LVN 1 stated the progress notes dated 8/24/23 indicated that the medication Heparin sodium was not available. During a concurrent observation and interview on 9/20/23, at 2:24 p.m. with LVN 1, in the Medication room, the facility's emergency kit was observed. LVN1 stated that Heparin Sodium Injection was available in the facility's Emergency Kit (Ekit) and should have been given to the resident as per Physician orders if unavailable in the medication cart. LVN 1 stated it was important to provide Heparin Sodium to Resident 1 to prevent blood clots. During an interview on 9/20/23, at 2:52 p.m. with LVN 2, LVN 2 stated on 8/24/23 she was not able to find the medication in the medication cart and called pharmacy to follow up but did not check the Ekit at the facility and did not administer Heparin sodium from the Ekit. During an interview on 9/20/23, at 2:30 p.m. with Director of Nursing (DON), the DON stated it was not acceptable that the Licensed Nurses did not administer Heparin Sodium to Resident 1 when it was (continued on next page) Any deficiency statement ending with an asterisk (*) denotes a deficiency which the institution may be excused from correcting providing it is determined that other safeguards provide sufficient protection to the patients. (See instructions.) Except for nursing homes, the findings stated above are disclosable 90 days following the date of survey whether or not a plan of correction is provided. For nursing homes, the above findings and plans of correction are disclosable 14 days following the date these documents are made available to the facility. If deficiencies are cited, an approved plan of correction is requisite to continued program participation. LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRESENTATIVE'S SIGNATURE TITLE (X6) DATE FORM CMS-2567 (02/99) Previous Versions Obsolete Facility ID: If continuation sheet Page 1 of 2 Event ID: 555341 Printed: 05/15/2026 Form Approved OMB No. 0938-0391 Department of Health & Human Services Centers for Medicare & Medicaid Services STATEMENT OF DEFICIENCIES AND PLAN OF CORRECTION (X1) PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION 555341 B. Wing A. Building (X3) DATE SURVEY COMPLETED 09/20/2023 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE Canyon Creek Post-Acute 22103 Redwood Road Castro Valley, CA 94546 For information on the nursing home's plan to correct this deficiency, please contact the nursing home or the state survey agency. (X4) ID PREFIX TAG SUMMARY STATEMENT OF DEFICIENCIES (Each deficiency must be preceded by full regulatory or LSC identifying information)